International assessment of massive transfusion protocol contents and indications for activation

Abstract

BACKGROUND Massive transfusion protocols (MTPs) provide blood products rapidly and in fixed amounts. MTPs are commonly used in trauma but may also be used in other clinical settings, although evidence to support fixed‐ratio resuscitation in nontraumatic hemorrhage is lacking. The goals of this study were to describe the types and contents of available MTPs and the clinical indications for MTP activation. METHODS A survey was distributed to 353 transfusion medicine specialists to assess the types and contents of available MTPs. Survey participants were invited to provide the clinical indications for consecutive adult and pediatric MTP activations for at least 6 months during 2015 to 2017. RESULTS There were 125 completed surveys (35% response rate) including three from children's specialty hospitals. Most hospitals that treated adult patients (90/122, 74%) utilized only one MTP for all adult bleeding emergencies, while one hospital had no MTP. Of the 31 hospitals that provided more than one adult MTP, 20 provided MTPs specific for obstetric bleeding cases. Of these, 50% (10/20) included at least one pool of cryoprecipitate or fibrinogen concentrate in the first MTP round, compared with 14% (13/90) of the hospitals with one MTP (p = 0.0012). Fifty‐seven hospitals provided the clinical indication for 4176 adult and 155 pediatric MTP activations. Although trauma was the single most common indication, the majority of adult (58%) and pediatric (65%) activations were for nontrauma indications. CONCLUSIONS The majority of hospitals use a single MTP to manage massive hemorrhage. The majority of MTP activations were for nontrauma indications.

Cold‐stored leukoreduced whole blood: Extending the time between donation and filtration has minimal impact on in vitro quality

“…With the introduction of component therapy, more patient‐tailored transfusion care could be provided, particularly for hematology‐oncology patients 2 . However, actively bleeding patients lose all components at once, essentially requiring the recapitulation of WB by sequentially transfusing all components in 1:1:1 or 1:1:2 ratios administered by massive transfusion protocols (MTPs) 3 . While this is standard‐of‐care in the resuscitation of severe hemorrhage, this approach leaves patients coagulopathic, and the recapitulated WB of the MTP is anemic and acidotic due to additives 4 .…”

How did we reform our out of control massive transfusion protocol program?

“…The electronic health record for each patient was examined and the principal reason for activating the MTP was determined and categorized per the legend. The 2016 data have been previously published as a subset of a much larger international multi‐site assessment of indications for MTP activation (reference 7) [Color figure can be viewed at wileyonlinelibrary.com]…”

“…Moreover, accrediting bodies now require massive transfusion laboratory policies, and having a formal MTP is a requirement by certain groups for patient blood management certification 1–5 . According to College of American Pathologists (CAP) survey data, >98% of all level I and level II trauma centers utilize an MTP 3,6,7 . However, the presence of an MTP does not necessarily equate to its appropriate usage or implementation, and transfusion services may become encumbered with MTP plans that require significant improvement.…”

“…The MTP allows for delivery of blood products in standardized amounts with relatively short turnaround times, and transfusion is based on clinical assessment of the bleeding patient, independent of laboratory testing. Current literature supports the usage of a 1:1:1 ratio (1 Red Blood Cell [RBC] unit:1 plasma unit:1 whole blood‐derived platelets unit), at least in the setting of trauma but the specifics of how to best establish an MTP service are unique to each medical center and patient population served 7–10 . Moreover, quality indicators should be evaluated to ensure that the MTP is activated appropriately, and that outcomes are optimized 11…”

Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

“…Inefficacious administration of non‐RBC components (fresh frozen plasma [FFP] and platelets) to treat MOH is associated with increased risk of dilutional coagulopathy (McDonnell & Browning, ; Gillissen et al , ). In many hospitals, management of MOH is now structured with massive transfusion protocols (MTPs), including early intervention and use of fixed ratios of non‐RBC:RBC components; however, protocols vary (Thomasson et al , ). Some hospitals use a single MTP for all causes of critical bleeding, commonly based on resuscitation strategies for trauma‐related bleeding.…”